Send to

Choose Destination
Surgeon. 2016 Jun;14(3):119-28. doi: 10.1016/j.surge.2014.06.005. Epub 2014 Jul 10.

Observation of behavioural markers of non-technical skills in the operating room and their relationship to intra-operative incidents.

Author information

Department of Surgery and Anaesthetics, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, Scotland, UK. Electronic address:
Department of Surgery and Anaesthetics, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, Scotland, UK.



The importance of non-technical skills in improving surgical safety and performance is now well recognised. Better understanding is needed of the impact that non-technical skills of the multi-disciplinary theatre team have on intra-operative incidents in the operating room (OR) using structured theatre-based assessment. The interaction of non-technical skills that influence surgical safety of the OR team will be explored and made more transparent.


Between May-August 2013, a range of procedures in general and vascular surgery in the Royal Infirmary of Edinburgh were performed. Non-technical skills behavioural markers and associated intra-operative incidents were recorded using established behavioural marking systems (NOTSS, ANTS and SPLINTS). Adherence to the surgical safety checklist was also observed.


A total of 51 procedures were observed, with 90 recorded incidents - 57 of which were considered avoidable. Poor situational awareness was a common area for surgeons and anaesthetists leading to most intra-operative incidents. Poor communication and teamwork across the whole OR team had a generally large impact on intra-operative incidents. Leadership was shown to be an essential set of skills for the surgeons as demonstrated by the high correlation of poor leadership with intra-operative incidents. Team-working and management skills appeared to be especially important for anaesthetists in the recovery from an intra-operative incident.


A significant number of avoidable incidents occur during operative procedures. These can all be linked to failures in non-technical skills. Better training of both individual and team in non-technical skills is needed in order to improve patient safety in the operating room.


Awareness*; Clinical competence*; Cognition*; Communication*; Curriculum*; Decision making; General surgery/education; General surgery/standards*; Humans; Interpersonal relations*; Leadership; Medical errors/trends*; Patient care team; Professional competence*; Professional practice/standards*; Psychomotor performance*; Task performance and analysis*

[Indexed for MEDLINE]

Supplemental Content

Full text links

Icon for Elsevier Science
Loading ...
Support Center